Anti–SARS-CoV-2 Pharmacotherapies Among Nonhospitalized US Veterans, January 2022 to January 2023

Abstract

ImportanceSeveral pharmacotherapies have been authorized to treat nonhospitalized persons with symptomatic COVID-19. Longitudinal information on the use of these therapies is needed.ObjectiveTo analyze trends and factors associated with prescription of outpatient COVID-19 pharmacotherapies within the Veterans Health Administration (VHA).Design, Setting, and ParticipantsThis cohort study evaluated nonhospitalized veterans in VHA care who tested positive for SARS-CoV-2 from January 2022 through January 2023 using VHA and linked Community Care and Medicare databases.ExposuresDemographic characteristics, underlying medical conditions, COVID-19 vaccination, and regional and local systems of care, including Veterans Integrated Services Networks (VISNs).Main Outcomes and MeasuresMonthly receipt of any COVID-19 pharmacotherapy (nirmatrelvir-ritonavir, molnupiravir, sotrovimab, or bebtelovimab) was described. Multivariable logistic regression was used to identify factors independently associated with receipt of any vs no COVID-19 pharmacotherapy.ResultsAmong 285 710 veterans (median [IQR] age, 63.1 [49.9-73.7] years; 247 358 males [86.6%]; 28 444 Hispanic [10.0%]; 61 269 Black [21.4%] and 198 863 White [69.6%]) who tested positive for SARS-CoV-2 between January 2022 and January 2023, the proportion receiving any pharmacotherapy increased from 3285 of 102 343 veterans (3.2%) in January 2022 to 5180 of 21 688 veterans (23.9%) in August 2022. The proportion declined to 2194 of 10 551 veterans (20.8%) by January 2023. Across VISNs, the range in proportion of patients who tested positive who received nirmatrelvir-ritonavir or molnupiravir during January 2023 was 41 of 692 veterans (5.9%) to 106 of 494 veterans (21.4%) and 2.1% to 120 of 1074 veterans (11.1%), respectively. Veterans receiving any treatment were more likely to be older (adjusted odds ratio [aOR] for ages 65-74 vs 50-64 years, 1.18; 95% CI, 1.14-1.22; aOR for ages ≥75 vs 50-64 years, 1.19; 95% CI, 1.15-1.23) and have a higher Charlson Comorbidity Index score (aOR for CCI ≥6 vs 0, 1.52; 95% CI, 1.44-1.59). Compared with White veterans, Black veterans (aOR, 1.06; 95% CI, 1.02-1.09) were more likely to receive treatment, and compared with non-Hispanic veterans, Hispanic veterans (aOR 1.06; 95% CI, 1.01-1.11) were more likely to receive treatment.Conclusions And RelevanceThis study found that prescription of outpatient COVID-19 pharmacotherapies in the VHA peaked in August 2022 and declined thereafter. There were large regional differences in patterns of nirmatrelvir-ritonavir and molnupiravir use.

Severe COVID-19 in Vaccinated Adults With Hematologic Cancers in the Veterans Health Administration

“…Oral antivirals and MABs may also have been received outside the VHA, and use of remdesivir for nonsevere disease could not be distinguished from use for severe disease . Missed documentation of either additional vaccine doses or antiviral treatment would reduce the estimated magnitude of benefit.…”

“…In contrast, findings with antiviral treatment were encouraging, indicating that use should be promoted and facilitated in patients with hematologic malignant neoplasms. Since only 26.1% of patients with infection after February 2022 had a record of having received antivirals, barely higher than in the VA population as a whole, 15 approaches to improve uptake of early antiviral treatment should be investigated and implemented.…”

“…Oral antivirals and MABs may also have been received outside the VHA, and use of remdesivir for nonsevere disease could not be distinguished from use for severe disease. 15 Missed documentation of either additional vaccine doses or antiviral treatment would reduce the estimated magnitude of benefit. In contrast, initial presentation with severe disease, as a contraindication for oral antiviral or MAB therapy, would magnify the apparent benefit of antivirals.…”

Underuse of Antiviral Drugs to Prevent Progression to Severe COVID-19 — Veterans Health Administration, March–September 2022

“…Despite demonstrated effectiveness and guideline endorsement ( 3 , 4 ), use of antiviral medications appears to be considerably lower than expected, based on the prevalence of risk factors for severe COVID-19. A recent study of patients in the Veterans Health Administration (VA) reported use of outpatient antiviral medications among 24% of all documented SARS-CoV-2 infections in 2022, remaining at that level through early 2023 ( 5 ). Description of the untreated comparison group clearly showed that many patients would have met treatment criteria.…”

Proportion of Hospitalizations Preventable with Increased Oral SARS-CoV-2 Antiviral Treatment

“…1,2 However, prescribing gaps exist among nonhospitalized SARS-CoV-2-infected patients with risk factors for progressing to severe COVID-19. 3 To demonstrate the potential impact of improving guideline-concordant oral antiviral prescribing, we estimated the proportion of hospitalizations that could have been averted had all eligible individuals in a clinical cohort been treated early in infection.…”